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Ethical Leadership: Needed Now More than Ever
Carol Taylor, PhD, RN Georgetown University School of Nursing
and Health Studies [email protected]
• Thanks for coming to this session—from your staff and me!
• Why this matters…
What words/images come to your mind when you hear the word
“leader”?
Leadership The ability to motivate an individual or
group to achieve valued goals
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ANA Standards of Nursing Practice. Standard
15. Leadership
• Engages in teamwork as a team player and a team builder.
• Works to create and maintain healthy work environments in local, regional, national, or international communities.
• Displays the ability to define a clear vision, the associated goals, and a plan to implement and measure progress.
• Demonstrates a commitment to continuous, lifelong learning for self and others.
• Teaches others to succeed by mentoring and other strategies.
• Exhibits creativity and flexibility through times of change.
• Demonstrates energy, excitement, and a passion for quality work.
• Willingly accepts mistakes by self and others, thereby creating a culture in which risk-taking is not only safe but expected.
• •Inspires loyalty through valuing of people as the most precious asset in an organization.
• Directs the coordination of care across settings and among caregivers, including oversight of licensed and unlicensed personnel in any assigned or delegated tasks.
• Serves in key roles in the work setting by participating on committees, councils, and administrative teams.
• Promotes advancement of the profession through participation in professional organizations.
• Ethical Leadership is the ability to direct or motivate an individual or group to achieve set ethical goals
• Ethical Leaders “stand out” because they role model:
– Ethical character
– Ethical decision making
– Ethical behavior
Checklist never, sometimes, often, always
• I routinely recognize ethical challenges in practice and I am confident in my ability to help staff respond effectively to these challenges.
• I know and am able to access the ethical resources in my institution. • I have confidence in my ability to respond to ethical challenges. • I have confidence in my institution’s ability to respond to ethical
challenges. • My staff respects me as an ethical leader who models ethical
character, decision-making, and behavior
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Traits of Ethical Leaders
• Dignity and respectfulness
• Serving others
• Justice
• Community building
• Honesty [http://managementstudyguide.com/leadership-ethics.htm]
Thornton’s Steps to Ethical Leadership
• Model ethical behavior
• Adopt transparency in decision-making and communications
• Establish a formal ethics or values statement
• Insist everyone meets ethical expectations
• Recognize and reward examples of ethical behavior
• Talk about ethics as an ongoing learning journey, not a once a year training program
Next Steps
• Community Tool Box: Section 8. Ethical Leadership. Retrieved http://ctb.ku.edu/en/table-of-contents/leadership/leadership-ideas/ethical-leadership/main
Objectives Upon completion of this session participants will be able to:
• Define ethics, moral agency, moral integrity, and ethical leadership
• Describe how both individuals and institutions develop moral agency and integrity and the consequences of honoring or dishonoring integrity
• Evaluate the nurse leader’s role in creating an ethical culture that supports staff doing the right thing, simply because it is the right thing to do
• Distinguish ethics concerns/challenges and related resources from legal, safety/quality, human resources, etc. concerns/challenges
• Develop strategies for nurse leaders to address moral distress and promote moral resilience
OUR JOBS AREN’T GETTING EASIER NOR IS ETHICAL PRACTICE…
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Scenario
• Pat is a 33 year old critical care nurse working in a 12 bed medical intensive care unit. You’ve worked with Pat for ten years and have recently noticed troubling changes in the quality of her patient care. When you ask her about what seem to be important deficiencies she tells you that she’s tired of trying to make health care work.
• “From now on, nursing is just a job and I’ll give an honest day’s labor for a day’s pay. But I’ve stopped trying to be everything for everybody. You get paid the same for showing up as you do for working your tail off to be the critical difference.”
• Pat feels like all the care and compassion have been wrung out of her. “People just aren’t grateful any more. They aren’t worth the tender loving care I used to lavish on my patients.” “And don’t get me started on administration…”
What makes ethical practice challenging in today’s practice environments?
• Profit versus care orientation—linked to demand to get dollars out of hospitals and into the community
• Patient engagement scores, rate of readmissions linked to millions of dollars
• Work loads, EMRs, tech demands, relentless pace
• Role modeling…
• What else???
A man grows most tired while standing still. Chinese Proverb
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What is Ethics?
What is Ethics?
• Ethics is the formal study of who we ought to be and how we should make decisions and behave in light of our identity
WHAT IS IT REASONABLE TO EXPECT OF NURSES TODAY?
ANA’s Foundations of Nursing Package
• the Code of Ethics for Nurses,
• The Nursing Social Policy Statement, and
• Nursing Scope and Standards.
AACN Mission
• Patients and their families rely on nurses at the most vulnerable times of their lives. Acute and critical care nurses rely on AACN for expert knowledge and the influence to fulfill their promise to patients and their families. AACN drives excellence because nothing less is acceptable.
AACN Values
• Ethical accountability and integrity in relationships, organizational decisions and stewardship of resources.
• Leadership to enable individuals to make their optimal contribution through lifelong learning, critical thinking and inquiry.
• Excellence and innovation at every level of the organization to advance the profession.
• Collaboration to ensure quality patient-and family-focused care.
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• Today’s health care professionals are competent, compassionate, collaborative advocates for patients and families. They are remembered by patients and families for making the critical difference in their hospitalization.
The Power (and limits) of One Nurse
A good nurse competently, compassionately, collaboratively advocates for patients and families…
One who is remembered for being or making the critical difference.
• BSHI nurses…. We can’t be this if no one advocates for us!
Paradigm Cases
When the Plan of Care Isn’t Working
When Patient Centered Care is a Myth
When Patients, Families, and Professional Caregivers Suffer Alone
Bullying…What would a zero tolerance policy for disrespect look like in our work environments?
Incompetent, Unethical, or Illegal Practice
Other:
“In the past we asked, what can I fix? Today we say, how can I help what’s wrong with you? In the future, we need to say, how can I help you live your life fully? Dr. Gaudet, U.S. Dept. of Veterans Affairs
• Person-centered care is all we talk about but is it a reality where you work?
Moral Agency
• Moral agency is the capacity to habitually act in an ethical manner, to be able to be counted on to do the right thing for the right reasons. It is unrealistic to assume that the simple desire to be a nurse is accompanied by the natural ability to behave in an ethical way. This ability, moral agency, must be cultivated in the same way that nurses cultivate the ability to do the scientifically right thing in response to a physiologic alteration. Nurses who appreciate the ethical challenges in professional practice value their ethical development sufficiently to work hard to develop these skills.
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This requires formation… How would you evaluate your
moral agency?
What signals you to an ethical challenge?
• Intellectual disconnect?
• Queasy feeling in the pit of your stomach?
• Discomfort or disappointment in the way you or your team are responding?
• “Yuck” factor!
Response
• Pay attention to how you reason as you think about how you should and would respond.
What counts as a good response?
– Promotes human dignity and the common good
– Maximize good and minimize harm
– Just distribution of goods and harms
– Respects rights
– Responsive to vulnerabilities
– Promotes virtue
– Other
What criteria do you use to evaluate your response?
– We stayed out of trouble—not greatly inconvenienced.
– We made money or at the very least didn’t lose money!
– Able to put your head on your pillow and fall asleep peacefully
– My/our reputation is intact.
– Transparency [Washington Post test; “I could share how I/we responded with my children and feel proud.”]
– Consistency
– Other
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Ethically competent health care professionals:
• Are competent for their role responsibilities
• can be trusted
• Are accountable
• work collaboratively to advocate for patients, families, and communities
Ethically competent health care professionals:
• mediate ethical conflict
• recognize the ethical dimensions of practice and identify and respond to ethical problems
– three ways to respond
• Critique, critique, critique
• One of a nurse leader’s challenges is recognizing ethical challenges and knowing how to leverage individual and institutional resources to address the challenge
We begin to see the challenges
of translating our good
judgments about what ought to
be done into moral action…
moral practice
Purpose of this Session
• Our Code of Ethics states clearly that the nurse’s primary commitment is to the patient, whether that be an individual, family or community.
• The public believes that we take this seriously.
• Who each of us chooses to be everyday literally has the power to determine the life and wellbeing of those we serve.
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How ethically buff are you and your team? We know the right thing to do but
it is almost impossible…
• Deficient moral agency
• Ethical Distress: inability to translate our good judgments about what ought to be done into moral action… moral practice.
Moral Distress
• Andy Jameton (1984) is credited with the first definition of moral distress when he sorted the moral and ethical problems in the hospital into moral uncertainty, moral dilemmas, and moral distress. “Moral distress arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of actions” (p. 6).
What nurses can do to address moral distress [Hylton Rushton, C., Caldwell, M. & Kurtz, M. (2016). Moral distress: A catalyst in building moral
resilience. American Journal of Nursing, 116(7), 40-50.]
• Recognize the symptoms of moral distress • Reflect on and be curious about the ethical aspects of
clinical situations • Reconnect to your original purpose and intention for being
a nurse • Commit to your personal well-being • Support and restore your moral integrity • Learn to listen to your intuition and somatic responses • Develop ethical competence • Speak up about your ethical concerns • Take principled actions • Contribute to a culture of ethical practice
Questions for Reflection:
• Have you ever felt uncomfortable because you believed you knew the right thing to do in a practice situation but were prevented from acting on your beliefs by internal or external variables? This is called moral distress.
• Do you have resources to consult when experiencing moral distress? What are they? How helpful do you find them?
• When moral distress continues unchallenged it can result in our disengaging from distressing situations as a means of protecting ourselves. This can compromise our clinical effectiveness, patient outcomes, and our own sense of well-being. Have you ever experienced this cycle of disengagement?
• Would you describe yourself as morally resilient? When times get tough do your thrive and flourish?
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Moral distress occurs when clinicians are unable to translate their moral choices into moral action. In such instances, acting in a manner contrary to personal and professional values undermines the individual's integrity and authenticity. Moral distress involves an irreconcilable conflict between one's ethical commitments and the action required for congruence between or among them. (Rushton, 2006).
• problems
• uncertainty
• dilemmas
• distress
• residue
• disengagement
• violation
• courage (Canadian Nurses Association)
Ethical…
Types of Ethical (or moral) Experience
Ethical Distress
Moral Residue
Disengagement
Epstein and Hamric’s crescendo effect
• Moral distress crescendo (here we go again…)
• Moral residue crescendo
• Numbing of moral sensitivity and withdrawal from involvement
• Conscientious objection
• Burnout and leaving a position or the profession itself
Constraints involved in moral distress (Epstein & Hamric, 2009)
Internal Constraints
• Lack of assertiveness
• Self-doubt
• Socialization to follow orders
• Perceived powerlessness
• Lack of understanding of full situation
Constraints involved in moral distress (Epstein & Hamric, 2009)
External Constraints • Inadequate staffing • Hierarchies within the healthcare system • Lack of collegial relationships • Lack of administrative support • Policies and priorities that conflict with care
needs • Compromised care due to pressure to reduce
costs • Fear of litigation
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Consequences of not addressing moral distress
• Lost capacity to care, avoidance of patient contact (disengagement), failure to give good care
• Physical and psychological problems • Diminished self-worth and moral integrity or moral well-being • Transferring from a department/service/place of work leaving
profession • Poor communication, lack of trust, high turnover rates,
defensiveness, and lack of collaboration across disciplines • Abusive behaviors, disrespectful communication, or worse • Erosion of team cohesion, intensifying the distress of the situation • Quality of patient care suffers (AACN’s 4 A’s to Rise Above Moral
Distress)
Resilience
• The ability to become strong, healthy or successful again after something bad happens.
• A combination of factors contributes to resilience. Many studies show that the primary factor in resilience is having caring and supportive relationships within and outside the family. Several additional factors are associated with resilience, including:
• The capacity to make realistic plans and take steps to carry them out.
• A positive view of yourself and confidence in your strengths and abilities.
• Skills in communication and problem solving. • The capacity to manage strong feelings and impulses. • All of these are factors that people can develop in themselves.
Ways to Promote Resilience Carol Taylor
• Begin and end the day with gratitude… • Practice mindfulness…what is the most important thing
right now? • Appreciate that all humans are limited… some things can’t
be “fixed” • Appreciate the power of connectedness and presence… • Stop frequently to stretch and take deep diaphragmatic
breaths • Reflect frequently on what brings you joy, makes you smile • Keep a positive, hopeful outlook (hope allows us to
envision a positive future and work to bring this into being)
Mindfulness and Self-Care http://www.nhchc.org/Clinicians/ResourceGuideforStaffRetreats.pdf
• When you awaken, express gratitude for your home, your work, your family/friends, your health or movement towards health.
• Say “thank you” and “you’re welcome” frequently
• When caught up in a stressful situation, ask yourself, “What is the most important thing right now?”
• Take mini stretch breaks throughout the day.
• Be willing to say, “I don’t know.”
• Ask for help and support when you need it.
• Create a personal mission statement for your work.
Mindfulness and Self-Care
• Place a post-it at the work station or on your computer that says BREATHE.
• Monitor your intake of caffeine, alcohol, salt, and sugar.
• Take a technology break—spend one day at home without answering the phone, email, or fax.
• Take a media break—spend one day at home without listening to the radio, news, watching TV or reading the newspaper.
• Place photos or pictures in your workplace of things or people that bring you joy
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Mindfulness and Self-Care
• For four hours try to do one thing at a time, avoid multi-tasking
• Keep a humor file. • If you feel a little too busy, stop and take 5
conscious, deep, diaphragmatic breaths. • If you feel moderately busy, stop and take 10
conscious, deep, diaphragmatic breaths. • When you go to bed at night, express gratitude
for the day you were given…for your home…your work…your family and friends... your health or movement towards health.
A Closing Word about Strategies
• Identify a trusted and respected confidant
• Communicate, communicate, communicate
• Make resolving ethical conflict a core competence and get reports on how this is being accomplished in annual performance reviews.
Strategies
• Identify ethical conflict EARLY and be proactive
• Make sure nurse managers appreciate nursing’s role in preventing and resolving conflict and are skilled in accessing ethics resources for nurses
• Utilize the ethics consultants/committee for individual cases as well as for addressing recurrent challenges
Denise Thornby’s challenge:
• Make “waves” • Courage is derived from
the French work, coeur, meaning heart…
• How courageous are you in the face of health care not working for those who need it? How skilled are you in effecting needed change?
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Denise Thornby Obituary August 2, 2012
• "Every day, every moment, you make choices on how to act or respond. Through these acts, you have the power to positively influence. As John Quincy Adams sagely said, 'The influence of each human being on others in this life is a kind of immortality.' So I ask you: What will be your act of courage? How will you influence your environment? What will be your legacy?”
What will be our legacy?
• Your picture here….
